Workers Medical Treatment Disputes Case Studies

TREATMENT DISPUTE

Our client suffered a badly torn hamstring requiring surgical repair. This caused him to limp for a prolonged period resulting in significant aggravation of osteoarthritis in the hip, eventually requiring hip replacement. The insurer denied liability for the cost of the hip replacement. We proceeded through the Workers Compensation Commission and our client was awarded a lump sum payment for permanent impairment, and the cost of the hip replacement.

SURGERY REQUEST UPHELD

Our client, a 42 year old female, fell at work sustaining an injury to her back. Her treating specialist recommended a back operation.

A request was sent to the Workers Compensation insurer who arranged for her to be seen by their own medico legal doctor for a second opinion. The report came back in favour of the insurer as their doctor advised the need for surgery was due to the degenerative process.

We sought to challenge the insurer’s decision and the Workers Compensation Commission Approved Medical Specialist (AMS) found in favour of our client’s requirement for surgery.

Whilst the report from the AMS was not binding on the insurer, the solicitors acting on behalf of the insurer agreed to accept the recommendations made by the AMS, that surgery was reasonably necessary and agreed to pay.

Our client has now undergone surgery, and we are now looking at further compensation for a lump sum for her as well as a claim in negligence.

As this was a matter that we received legal funding through the WorkCover Review Office, (WIRO) our costs and disbursements were covered and our client was not required to pay any legal costs or make any payment towards disbursements, including medical reports.

BATTLE WITH INSURER FOR SURGERY

Our client was a young man in his early 20’s who sustained a significant back injury whilst carrying out heavy lifting. His treating neurosurgeon recommended a conservative approach before he would operate and the workers compensation insurer approved pain management, as well as three cortisone injections and core strengthening exercises for his back.

Unfortunately these conservative measures did not assist our client and approval was then submitted to the insurer to proceed with surgery. The insurer disputed requirement for surgery, so proceedings were commenced seeking to challenge the insurer’s decision.

The Workers Compensation Commission referred our client to an Independent doctor whose opinion is not binding but persuasive. This independent doctor was of the view that our client should undergo pain management and did not agree with proposed fusion operation put forward by our client’s specialist.

We ended up proceeding to arbitration and were successful in arguing before the arbitrator that surgery was reasonably necessary as our client had tried all conservative means of alternative treatment, which showed little abatement of our client’s symptoms.